Background

Pelvic organ prolapse (POP) is a common condition that is increasing in incidence. Many cases of prolapse of the posterior vaginal wall occur along with other pelvic support defects. Pelvic surgeons who treat rectocele must have an excellent understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship between anatomy and function. These pelvic support defects may or may not cause symptoms. Pelvic pressure, vaginal protrusion, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been described in patients with rectoceles. Whether prolapse is the cause or result of these symptoms is uncertain.[1]

This article focuses on (1) current knowledge regarding the relationship of rectocele anatomy and function and (2) useful evaluations and treatments for women with rectoceles and defecation disorders.

History of the Procedure

The surgical treatment of rectocele since the early 19th century has been the posterior colporrhaphy. This procedure was originally designed to repair perineal tears and included plication of the pubococcygeus muscles and the posterior vaginal wall (effectively creating a perineal shelf and partially closing the genital hiatus) with reconstruction of the perineal body.[2]

Richardson has advocated the site-specific repair of discrete breaks or tears in the rectovaginal septum.[3] This approach aims for a more anatomic repair. Other considerations for treatment include the approach (transvaginal vs transanal) and the introduction of different types of grafts or "kits" to attempt improvement of the longevity of the procedure.

Sites of occurrence.

Epidemiology

Frequency

POP is very common, and it is the indication for more than 200,000 surgeries in the United States annually.[4] The number of women seeking care for pelvic organ prolapse is predicted to increase by 45% over the next few years.[5, 6]

Ambulatory women have a reported prevalence rate of pelvic organ prolapse of 30-93%. One of the difficulties in reviewing studies of pelvic organ prolapse is that these studies include all support defects (eg, defects of the vaginal apex, anterior wall, posterior wall), although most women have support defects at multiple locations. It is difficult to determine the prevalence of POP in ambulatory women, since most POP is mild, with prolapse beyond the vaginal introitus occurring in less than 5% of cases.[7]

Data on symptomatic women with prolapse are somewhat more robust. In a review of 149,544 women, Olsen et al found an 11.1% lifetime risk of surgery for pelvic organ prolapse or urinary incontinence. Approximately 40% of these women had posterior support defects.[8]

Thus, POP and rectocele are relatively common, although the supporting data are limited. The incidence of POP and rectocele increases with age, parity, and BMI. However, even nulliparous women may present with a clinically significant rectocele, albeit relatively uncommon.

Etiology

Rectocele and other forms of POP are the result of women attaining an erect bipedal posture. Etiologically, most cases are the result of vaginal childbirth[9] and chronic increases in intra-abdominal pressure (such as chronic constipation). In some patients, rectocele is thought to develop as a result of congenital or inherited weaknesses within the pelvic support system.

A number of iatrogenic factors may contribute to POP, including failure to adequately correct all pelvic support defects during pelvic reconstructive surgery. In some patients, the failure to reattach the endopelvic fascia to the perineal body at the time of vaginal delivery leads to a site-specific defect in the endopelvic fascia. Additionally, procedures that alter the direction of pelvic forces can cause areas to prolapse that previously had been adequately supported. Examples include (1) ventral suspensions of the urethra, uterus, or vagina that increase exposure of the cul-de-sac to increases in intra-abdominal pressure; (2) posterior fixation of the vaginal apex; (3) failure to detect and correct an occult enterocele; and (4) excessive shortening of the vagina.

Pathophysiology

Rectocele is a defect of the rectovaginal septum, not the rectum. The pelvic surgeon must know the anatomy of the pelvic floor and the other supports of the vagina in order to diagnose and treat this disorder.

The muscular support of the pelvis is from the pelvic diaphragm. The pelvic diaphragm is made up of a group of paired muscles that include the levator ani and coccygeus muscles. The levator ani are composed of the puborectalis, pubococcygeus, and ileococcygeus muscles. These muscles have their origin at the pubic rami on either side of the midline at the level of the arcus tendineus levator ani. The muscle fibers of the levator ani pass lateral to the vagina and rectum, creating a sling surrounding the genital hiatus. They also create the pelvic floor posteriorly and laterally. When a woman contracts the levator ani, the pelvic diaphragm provides a horizontal shelf where the pelvic viscera lie and the genital hiatus closes.

The thin membranous connective tissue in the rectovaginal septum (and surrounding the entire vaginal tube) is called the Denonvilliers aponeurosis (fascia) or endopelvic fascia and is fused to the underside of the posterior vaginal wall. This rectovaginal fascia extends downward from the posterior aspect of the cervix and cardinal-uterosacral ligaments to its attachment on the upper margin of the perineal body; then, it laterally extends to the fascia over the levator ani muscles. The cardinal and uterosacral ligaments pull the vagina horizontally toward the sacrum, suspending it over the muscular levator plate.

The perineal body is located between the vaginal introitus and anus. It is the attachment for the perineal membrane (bulbocavernosus muscles, superficial transverse perineal muscles, and investing fascia), a portion of the levator ani, the external anal sphincter, and the rectovaginal (endopelvic) fascia. Through its attachment to the cardinal and uterosacral ligaments, the rectovaginal septum stabilizes the perineal body, which is essentially suspended from the sacrum. The perineal body is further stabilized through the lateral attachments of the perineal membrane to the ischiopubic rami. Between the lateral and superior support, the downward mobility of the perineal body is limited. However, if this attachment is separated, as can occur during childbirth, the perineal body can become more mobile, leading to rectocele and perineal descent.[10]

Presentation

Patients with rectocele often present with feelings of pelvic pressure, a sensation of "bearing-down," or a perception that something is "falling out." Symptoms are often accentuated by standing and lifting and relieved by lying down. Symptoms directly related to the prolapse include the sensation of a mass or bulge in the vagina, pelvic pressure and pain, low back pain, and difficulty with intravaginal intercourse. Symptoms directly related to rectocele include defecatory dysfunction, inability to completely evacuate the distal rectum without straining, constipation, and dyspareunia.[11] However, constipation is considered a colonic motility disorder not treated by posterior surgery.[12]

Indications

Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. Indications for surgery include the desire for definitive surgical correction of the mass or bulge in the vagina, pelvic pressure and pain, low back pain, difficulty with intravaginal intercourse, recurrent vaginal ulcerations due to pessary use, or fecal incontinence that the patient deems unacceptable.

Using strict indications for surgical repair of symptomatic rectoceles appears to improve surgical outcomes, including quality of life and a reduction in recurrence rates.[13] Hall et al used dynamic magnetic resonance imaging defecography (MRID) to evaluate 143 patients with obstructive defecation syndrome over an 8-year period (2006-2013). Seventeen patients met the following criteria and underwent surgical repair:

Relevant Anatomy

Histologically, the apex of the posterior vaginal wall consists of squamous epithelium, a superficial and deep muscularis layer and an adventitial layer. The fibromuscular layer is commonly called the rectovaginal fascia. Kleeman et al have described the histology of the rectovaginal septum. The apical portion is mostly adipose tissue while the midportion consists of an adventitial layer containing fat, fibrous tissue, blood vessels, nerves, and elastic fibers. The distal portion at the level of the perineal body contains dense connective tissue.[14]

Anatomically, the pelvic organs are maintained within the bony pelvis by levator ani muscles that are posteriorly fused (pelvic floor). The levator ani muscles are attached to the bony pelvis anteriorly and posteriorly; laterally, they are attached to the arcus tendineus musculi levatoris ani, which overlie the obturator internus muscles of the pelvic sidewalls. The anterior separation between the levator ani is called the levator hiatus. Inferiorly, the urogenital diaphragm covers the levator hiatus. The urethra, vagina, and rectum pass through the levator hiatus and urogenital diaphragm as they exit the pelvis. The posterior joining of the levator ani in the midline by the anococcygeal ligament forms the levator plate. DeLancey has described the 3 levels of pelvic support.[15]

View Image

The vagina and supportive structures. Paracolpium extends along the lateral wall of the vagina.

View Image

Level I is suspension and level II is attachment. The paracolpium suspends the vagina from the lateral pelvic walls in level I. These fibers extend ve....

View Image

Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior ....

The perineal body is a central point for the attachment of the perineal musculature. The perineal body lies beneath and supports the pelvic diaphragm. The distal posterior wall of the vagina is fused to the ventral surface of the perineal body. The perineal body is also important to the support of the rectum. The pelvic organs, their interrelationships, and their support systems must be thought of conceptually and functionally in 3 dimensions (see above images).

Although the contents of the abdominal cavity bear down on the pelvic organs, they remain suspended in their relation to each other and to the underlying levator sling and perineal body. Each organ is capable of independent function because it is separated from other organs by connective-tissue spaces within the endopelvic connective-tissue support system. The normal tonic contraction of the levator ani muscles supports the pelvic organs from below and contributes to urinary and fecal continence. Relaxation of the levator ani muscles allows descent of the pelvic organs and aids urination and defecation.

Contraindications

Physical Examination

The pelvic examination findings should define the degree of prolapse and help determine the integrity of the connective tissue and muscular support of the pelvic organs. The pelvic examination is best performed with the patient in the dorsal lithotomy position, with her head elevated 45° (which allows for maximal Valsalva). Rectocele is suspected when posterior wall bulging is noted.[11]

The extent of prolapse must be documented. One method is to measure the degree of descent with respect to the hymenal ring. The Pelvic Organ Prolapse Quantitation examination is the most widely accepted at this time and has been adopted by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons. The 9 measurements made are 6 topographical points on the vaginal walls, 2 topographical points on the perineum, and vaginal length.[16]

All portions of the vagina should be evaluated. This includes the vaginal apex, the anterior wall, and the posterior wall. The posterior wall is assessed while supporting the vaginal apex and anterior wall with a Sims speculum or with the posterior blade of a Graves speculum. This allows identification of the specific location of the defect in the rectovaginal fascia. The examiner may note that the rugae in the vaginal epithelium are lost overlying the defect in the endopelvic fascia. Generally, a pocket is observed just above the anal sphincter. Anterior displacement of the rectal wall observed upon rectovaginal examination is diagnostic of rectocele.[17]

A rectovaginal examination provides information regarding the integrity of the rectovaginal fascia, perineal body, and possible identification of an enterocele.

In a healthy woman, the perineum should be located at the level of the ischial tuberosities or within 2 cm of them. Diagnosis of perineal descent is made if the perineum is noted to be below this level either at rest or with straining. In a patient with perineal descent, widening of the genital hiatus and perineal body and flattening of the intergluteal sulcus may be seen. The degree of perineal descent can be objectively measured with a thin ruler placed in the posterior introitus at the level of the ischial tuberosities. Descent is measured as the distance the perineal body moves when the patient strains.

The bimanual examination is used to investigate the location, size, and tenderness of the cervix, uterus, bladder, and adnexa. The pelvic diaphragm should be assessed for integrity, as should the strength, duration, and anterior lift of the contraction. The firm muscular sling of the puborectalis should be palpable posteriorly because it creates a 90° angle between the anal and rectal canals. Voluntary contraction of this muscle pulls the examining finger anteriorly toward the muscle's insertion on the pubic rami.

Approach Considerations

Consider performing ancillary testing to ensure the patient has been evaluated for other types of pelvic floor dysfunction. The tests usually considered are physiological tests of bladder and rectal function and imaging tests to clarify anatomical derangements. Note the following:

Urodynamic testing is commonly used for patients with urinary incontinence in addition to pelvic organ prolapse, although the benefit of urodynamic testing in women without urinary incontinence is controversial.

Urodynamic testing with reduction of the posterior vaginal wall is recommended in patients with an equivocal diagnosis. Similarly, anorectal physiologic testing may be useful in patients with suspected anismus or concurrent fecal incontinence.

The most important consideration in a patient with rectocele is the presenting symptoms. In women with isolated herniation symptoms consistent with rectocele, further testing is probably not required.

Laboratory Studies

Imaging Studies

In women with defecatory dysfunction, a gastrointestinal evaluation, including a barium enema or colonoscopy, is recommended to eliminate colorectal malignancy from the differential diagnosis. Anoscopy may reveal anorectal pathology such as prolapsing hemorrhoids, and proctosigmoidoscopy helps to exclude intrarectal prolapse or a solitary rectal ulcer. Occasionally, referring the patient to an anorectal physiology laboratory may be necessary. This may be necessary to differentiate between patients with colonic motility disorders and those with predominant pelvic outlet symptoms.

Other radiologic studies that may be useful include the colonic transit study, pelvic floor fluoroscopy, and dynamic magnetic resonance imaging. Colonic transit studies involve the use of ingested radiopaque markers, followed by serial abdominal radiographs over a 5-day period. The woman ingests a capsule with 24 radiopaque markers, and then serial abdominal radiographs are taken every other day until all the markers are gone. Eighty percent of these markers should be passed by day 5. If less than 80% are passed, this suggests a motility disorder. Collection of the markers in the sigmoid is suggestive of outlet obstruction but is not diagnostic. The colonic motility test is primarily indicated for patients with a suspected motility disorder based on abnormal stool frequency (less often than every 3 d).

Pelvic floor fluoroscopy may be useful for patients with pelvic organ prolapse and severe defecatory dysfunction. It can be especially useful for women who report incomplete evacuation because it helps to differentiate causes of outlet obstruction such as anismus and support defects. The small bowel is opacified with oral contrast, the vagina and bladder with liquid contrast, and the rectum with contrast paste. A series of sagittal still films and cinevideographs are made with fluoroscopy while the patient sits and defecates on a radiolucent commode. Radiographs are taken at rest, during defecation, and while squeezing the anal sphincters. The size of the rectal ampulla, length of the anal canal, size of the anorectal angle, motion of the puborectalis, and degree of pelvic floor descent are measured. This provides both radiologic evidence of herniation of the surrounding organs into the vagina and dynamic assessment of pelvic floor function during defecation.

Rectoceles are commonly found on proctograms, and small bulges of the anterior rectal wall detected upon evacuation proctography might be normal findings because they are frequently asymptomatic. Rectoceles should be considered abnormal if barium trapping (the rectocele does not completely empty upon evacuation) is noted.

Pelvic floor fluoroscopy is considered the criterion standard for measuring perineal descent and is more accurate than physical examination for defining which organ is herniating into the vagina. However, it is usually reserved for patients with marked defecatory dysfunction.

Dynamic magnetic resonance imaging provides a similar evaluation. It also provides multiplanar information about the soft tissues of the pelvic floor. The most appropriate use of this test is for patients with complex pelvic organ prolapse or symptoms that are not explained by the physical examination findings.

Anismus can mimic the defecatory symptoms of posterior pelvic organ prolapse and can cause posterior pelvic organ prolapse as a result of outlet obstruction. This should remain a consideration in the differential diagnosis. Anismus is usually suspected in patients with tender, hypercontracted puborectalis muscles upon bimanual examination, especially if she cannot relax these muscles on command. Pelvic floor fluoroscopy can provide evidence of anismus, including lack of straightening of the anorectal angle and failure to evacuate two thirds of contrast after 30 seconds of straining. However, a balloon expulsion test and surface electromyography are considered superior for making the diagnosis of anismus.

Medical Therapy

Patients with rectoceles may present with an asymptomatic bulge found during the pelvic examination or with a myriad of symptoms. For patients without symptoms, expectant management is recommended. Currently, no evidence supports the use of estrogen to prevent or treat prolapse.[11]

Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele. Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications. One responsibility of the physician is to inform women of their treatment options and the potential benefits and risks of each option. Medical treatment options for women with symptoms primarily consist of fiber supplementation to manage stool consistency, splinting or management with pessaries. Physical therapy and biofeedback can also improve patient ability to defecate.

Prophylactic measures

Prophylactic measures for preventing rectocele include diagnosis and treatment of chronic respiratory and metabolic disorders, correction of constipation, and intra-abdominal disorders that may cause chronic increases in intra-abdominal pressure.

Counsel patients about the preventive effects of weight control, proper nutrition, smoking cessation, and avoidance of strenuous occupational and recreational stresses that could damage the pelvic support system. Teach and encourage women to perform pelvic muscle exercises as a method of strengthening their pelvic diaphragm and as prophylaxis against the development of rectocele.

Failure to recognize and treat significant support defects at the time of concomitant gynecologic surgery can lead to progression of rectocele. Similarly, opening up the genital hiatus by performing a retropubic urethropexy (eg, Burch procedure) can predispose a patient to enterocele and rectocele. Disabilities that may occur include inability to defecate without manual replacement of the uterus, bladder, or rectum; sexual dysfunction; and vaginal ulceration.

For mild degrees of relaxation, especially in younger women immediately following childbirth, levator muscle exercises, sometimes called Kegel exercises, are helpful in restoring the tone of the muscles of the pelvic floor. Instruct patients how to appropriately contract the puborectalis muscles. Patients should repeat this exercise approximately 75 times during the day. Like most forms of physical therapy, this is usually more effective in premenopausal women than in older women in whom generalized skeletal muscle atrophy has occurred. Learning appropriate relaxation of the puborectalis muscles with biofeedback may also help with evacuation.[18]

Pessaries

In addition to strengthening pelvic muscles, nonsurgical management of pelvic organ prolapse mainly involves fitting the patient with a vaginal pessary. Numerous vaginal pessaries are available that are designed to support specific types of pelvic organ prolapse.[19] Pessaries press against the walls of the vagina and are retained within the vagina by the tissues of the vaginal outlet. On occasion, the vagina and its outlet may be so dilated that it does not hold a pessary. If no other reasonable therapeutic option is available for such a patient, a perineorrhaphy can be performed with the patient under local anesthesia, thus constricting the vaginal outlet to enable it to retain a pessary.

Pessaries can cause vaginal irritation and ulceration. They are better tolerated when the vaginal epithelium is well estrogenized, making exogenous estrogen essential in the hypoestrogenic patient. Remove, clean, and reinsert vaginal pessaries periodically; failure to do so can result in serious consequences, including fistula formation.

Patients can be treated successfully with a pessary for years. Indications for surgery include the desire for definitive surgical correction, recurrent vaginal ulcerations due to pessary use, or genuine stress incontinence that the patient deems unacceptable.[11]

Surgical Therapy

Despite advances in understanding of pelvic floor anatomy, physiology, and disorders along with the advances in surgical techniques (including laparoscopy), no consensus exists regarding the optimal method of repair.[20] A variety of surgical techniques have been described, including posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal approaches.

In a comparison between transvaginal and transanal approach for rectocele repair, Leanza et al noted that although both approaches are effective for posterior compartment defects and improvement in quality of life, there are variations in outcome.[21] Gynecologists generally use the vaginal approach with successful anatomic results and minimal postprocedure pain, but sexual dysfunction is a concern. The transanal approach yields better rectal function and tends to be performed by general surgeon or proctologists.[21] Transvaginal repairs have had lower rates of recurrent prolapse.[22, 23, 24, 25, 19]

Historically, the primary surgical therapy for rectocele has been posterior colporrhaphy. The principal objective of the posterior repair is to repair perineal tears that occurred during vaginal delivery. The perineal closure is designed to narrow the caliber of the vaginal introitus, develop a perineal shelf, and partially close the genital hiatus. The original description described reduction of the rectocele, suturing of the levator ani muscles anterior to the rectum, repair of the perineal body, and correction of existing enterocele or prevention of potential enterocele.[2] Approximating the levator muscles in the midline increases the length of the levator plate, shortens the longitudinal and transverse diameters of the genital hiatus, and improves the competence of the pelvic valve. This, however, is a nonanatomical approach to pelvic floor dysfunction and rectocele repair and likely increases risks of dyspareunia.

Preoperative Details

Surgical repair of rectocele is indicated for a symptomatic patient with a rectocele caused by a rectovaginal fascial defect. The criteria necessary to perform a repair are in contrast to the outdated dictum that posterior colporrhaphy should always accompany anterior colporrhaphy.

Rectoceles can be diagnosed based on physical examination and imaging study findings. A prudent plan is to consider performing preoperative radiologic evaluations of unusual rectoceles or those associated with rectal prolapse. Detachment of the posterior vaginal wall does not necessarily confirm the presence of a rectocele. Consider posterior colporrhaphy or other surgical management as a distinct and separate procedure when pelvic organ prolapse is repaired.

Intraoperative Details

Posterior colporrhaphy

Depending on the need for reconstruction of the perineum, the skin can be incised in a V-shaped fashion over the perineum or transversely along the external margin of the posterior fourchette. The vaginal wall of the posterior fourchette is sharply dissected from the underlying tissues of the perineal body. The rectovaginal space is entered and widely dissected to the vaginal apex, beyond the top of the rectocele.

View Image

An Allis clamp tracts upward in the midline of the distal posterior vaginal wall at the site of the bulge. Traction is applied laterally and outward t....

View Image

In A, penetration with the fifth finger establishes direct access to the levator ani, bilaterally. In B, Allis clamps are placed on both sides. Tracti....

At this point, looking for an enterocele and repairing it as necessary is extremely important. The pararectal fascia is plicated over the rectum with interrupted, delayed, absorbable or permanent sutures from the vaginal apex to the introitus.

View Image

In A and B, rectocele is imbricated. Several layers may be required. Dense connective tissue must be identified and plicated. In C, levator ani are br....

As each suture is placed, the diameter of the vagina is assessed to ensure no transverse constriction is occurring that might result in dyspareunia. Linear, lateral, relaxing incisions relieve any constrictions that occur. If necessary, redundancy of the posterior vaginal wall flaps is trimmed and care is taken to preserve the vaginal caliber. The cut edges of the upper posterior vaginal wall are approximated in the midline. Plicating the muscle itself is not necessary; rather, plicate the capsule of the muscle. Plicating the capsule of the muscle most commonly involves the puborectalis muscle (this may risk dyspareunia). If a defective perineal body is present, its connective tissue is plicated in the midline. The remaining cut edges of the posterior vaginal wall and perineum are approximated.[26]

View Image

In A, a second suture is placed into the levator ani to reduce the dimension of the genital hiatus. The more anterior these sutures, the smaller the g....

View Image

In A, the perineal body is repaired. In B, the perineum is rebuilt. In C and D, the posterior vaginal wall is closed.

Perineorrhaphy

If a deficient perineal body is present after vaginal repair, consider performing a perineorrhaphy. The perineal deficit might be due to attenuation, laceration, or hypermobility of the perineal body. Whether levator ani plication adds to the success of the operation remains controversial due to concerns about dyspareunia. If any muscles are approximated in the midline, do not strangulate or destroy them. Take care to not constrict the posterior fourchette because this may result in dyspareunia.

Defect-directed or site-specific repair

Discrete tears or breaks have been described in the rectovaginal septum, most commonly transverse separation of the rectovaginal septum from the perineal body that are thought to be responsible for rectocele. Richardson described the defect-directed repair, or site-specific fascial repair, the aim of which is to provide an anatomical repair to close these fascial tears or defects.[3]

Begin with a midline epithelial incision and separate the epithelium from the rectovaginal fascia. The edges of the fascial defects or tears are identified; then, the defect is repaired with interrupted, delayed, absorbable sutures. Unlike the traditional posterior colporrhaphy, the sutures are placed from cephalad to caudad. The best plan is probably to repair the muscles of the perineal body, if separated, and then reconstruct the perineal body. The vaginal epithelium is then reapproximated; however, it is not intentionally narrowed, as with a posterior colporrhaphy.[3]

Most studies using the site-specific defect repair report very low rates of dyspareunia with good functional and anatomical outcomes.[27] However, some authors have noted that obstructed defecation is not corrected as successfully as the midline posterior colporrhaphy.[22]

Transanal repair

In the colorectal literature, the transanal repair has been advocated via the rectal side of the rectocele. This repair has several variations, but the purpose of the procedure is to remove or plicate the redundant rectal mucosa, thus decreasing the size of the rectal vault, and to plicate or repair the anterior rectal wall musculature.

Generally, the procedure is performed with the patient in the prone jackknife position. A U- or T-shaped incision is made transanally just above the dentate line. A mucosal flap is developed, separated from the rectovaginal septum, and excised. Then, the rectovaginal septum is plicated from the rectal side with absorbable sutures. The plication includes the anterior rectal musculature. The rectal mucosa and submucosa are closed in a separate layer.[26]

Advantages of this procedure include the excision of redundant rectal mucosa and the ability to deal with coincident anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse. Disadvantages include an inability to reconstruct the perineal body unless a second incision is made, an inability to correct an anal sphincter defect if present, and difficulty accessing a high rectocele. Complications of transanal repair include infection and rectovaginal fistula.

One major concern after transanal rectocele repair is postoperative anal incontinence. This significant problem has been described in up to 38% of patients after transanal repair.[28] Fecal incontinence may occur because of an occult sphincter laceration that causes symptoms with aging, or it may develop as a result of the anal dilation and stretching during the rectocele repair.

One area that deserves attention is the recurrent rate of prolapse. Two separate randomized trials have shown that the transanal approach has a significantly higher failure rate when compared with the transvaginal approach.[22, 24, 25]

A newer method of transrectal rectocele repair has been described.[29] The Stapled Transanal Rectal Resection or STARR procedure. An anal dilator (CAD 33) is introduced into the anal canal and the posterior rectal wall is protected by a retractor placed in the lower hole on the dilator. The dilator is then pushed along the anal canal. A PSA 33 anoscope is introduced into the dilator, and three half purse-strings permanent sutures placed which includes the prolapsed rectal wall with mucosa, submucosa and rectal muscle wall inserted above the hemorrhoidal apex .1–2 cm apart, including the top of rectocele or prolapse A 33 mm circular stapler is opened, and the head placed above the posterior vaginal valve and withdrawn. The anterior stapled line is reinforced using 3-0 absorbable sutures. The procedure is repeated in the posterior rectal wall, with the retractor inserted into the upper hole of the dilator.

A study by Zhang et al indicated that endoscopic stapled transanal rectal resection (STARR) is an effective treatment for rectocele. Sixty-one patients with severe rectocele underwent the procedure. The patients in the study had significant reduction or disappearance of the rectocele on defecography.[30]

Grafts

To prevent or reduce the risk of rectocele recurrence, a variety of graft materials and meshes have been used. These materials have been used in combination with the traditional methods of posterior colporrhaphy and in the defect-directed repair.[31]

In the case of a defect-directed repair, one may place a dermal allograft over the repair and secure it to the rectovaginal fascia cephalad, to the arcus tendineus fascia rectovaginalis laterally, and to the perineal body distally, which creates a second layer of support. Although the graft may strengthen the repair, graft materials may shrink. This can create a repair that is too tight and can decrease the flexibility of the posterior wall and cause restriction of the rectum, such that it cannot expand during accommodation or during coitus. This loss of flexibility in the posterior wall can lead to fecal urgency and dyspareunia.

If the use of graft material is considered the surgeon must choose the material with a very low rejection rate, be relatively inexpensive, decrease recurrence rates, and cause no harm with respect to bowel and sexual function. Currently, no good data support the use of one type of graft material over another. Many different materials have been used without clinical trials or long-term data to support their use.

Mesh kits

On July 13, 2011, the FDA issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.

The FDA’s update states, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.[33]

With the overwhelming success of monofilament polypropylene mesh midurethral slings for the treatment of urinary stress incontinence has come great interest in the use of these materials in other prolapse surgery. These vaginal mesh kits for posterior vaginal prolapse that have been developed place synthetic material in the rectovaginal space. The mesh or graft is suspended through the iliococcygeous fascia or sacrospinous ligaments. These procedures have gained wide use without appropriate long-term safety or outcomes data.

After the posterior vaginal wall is opened to a few centimeters from the apex, the surgeon makes stab incisions 3 cm lateral and 3 cm posterior from anus bilaterally. After palpating the ischial spine with 1 finger vaginally, a needle is passed on the same side through the perianal stab incision into the ischiorectal fossa. The finger in the vagina follows the needle tip to help protect the rectum. The needle is passed along the lateral pelvic sidewall toward the ischial spine and penetrates the levator muscle 1 cm distal to the ischial spine.

This is repeated on the contralateral side. The mesh is then connected to the needle and reversed back through the perianal skin incisions and the mesh is sutured to the apex of the vagina. The rest of the repair is performed in the traditional fashion and the mesh ends are cut and stab incisions closed.

In one study, the authors reported on 106 patients who had undergone an anterior, posterior, or total Prolift procedure. In this case series with 3 months of follow-up, they identified a 4.7% mesh erosion rate and 17% mesh shrinkage. The mesh erosions were treated with topical estrogen. Those who failed required surgical excision of the exposed mesh.[35]

Another group using the Apogee device retrospectively analyzed the outcomes of 120 women observed for 1 year.[36] The authors noted an 11% mesh erosion rate with a total of 4 women (3%) requiring excision of the mesh.

Current preliminary data is retrospective in nature and provides no comparative data to show differences between anatomic or functional cure rates using these devices compared with traditional procedures. Even in these preliminary studies, serious complications have been reported.

In January of 2017, The American Congress of Obstetricians and Gynecologists concluded “synthetic mesh or biologic grafts should not be placed routinely through posterior vaginal wall incisions to correct POP for primary repair of posterior vaginal wall prolapse.”[19]

Abdominal approach

This approach is most commonly used when correction of an accompanying enterocele or vault prolapse is indicated. Patients with rectocele often present with apical prolapse or defecatory problems, including chronic constipation or fecal incontinence. If the defect in the rectovaginal fascia is in the superior portion of the posterior vaginal wall, it can be repaired through the cul-de-sac during the sacral colpopexy.

Another modification of sacral colpopexy is the sacral colpoperineopexy. This procedure is used to treat perineal descent with posterior and apical pelvic organ prolapse. The aim of this procedure is to replace the normal support of the vagina and the continuous endopelvic fascia that runs from the sacrum to the perineal body. This procedure may be performed totally abdominally or as a combined abdominal and vaginal procedure.

From the abdominal approach, the peritoneum overlying the apex and posterior wall of the vagina is incised to open the rectovaginal space. Sutures are placed over the length of the posterior wall, from the apex to the perineal body. The perineal body is elevated by the surgeon's nondominant hand. Stitches are placed abdominally into, or as close to, the perineal body as possible. The permanent graft is placed abdominally between the posterior vaginal wall and the rectum. The sacrocolpopexy is completed with attachment of the anterior wall graft and posterior wall graft to the previously placed sacral sutures.

In the combined abdominal/vaginal approach, the sacral colpoperineopexy is performed as described above, except the perineal body sutures are placed transvaginally.

Levator ani plication

Although levator ani plication has been championed in the past, this procedure should rarely, if ever, be used during posterior colporrhaphy secondary to the significant increased risk of dyspareunia in sexually active women.[12]

Postoperative Details

Postoperative care usually consists of control of minor pain either with oral narcotics or with nonsteroidal anti-inflammatory drugs. For vaginal procedures, most patients are able to return home the same day. Of course, abdominal procedures mandate stronger analgesia such as patient-controlled analgesia, and the patient stays in the hospital for 2-3 days.

Complications

Immediate complications include adverse anesthesia reactions; hemorrhage; infection of the operative site or lower urinary tract; and injury of contiguous organs, blood vessels, or nerves. Infectious complications are rare (3-6%). Patients in whom graft material has been used have a graft erosion rate of up to 10%. Long-term complications include recurrent pelvic organ prolapse and dyspareunia in 20-30% of women.[26]

Outcome and Prognosis

Failure and/or recurrence rates are highly variable.[27] Important factors in prognosis are teaching patients to decrease intra-abdominal pressure through adequate control of respiratory illnesses and to decrease straining. Identifying and treating all pelvic floor defects at the time of the original surgery and Pelvic Organ Prolapse-Quantified system (POP-Q) stage are the greatest predictors of long-term success.

Future and Controversies

Individualize management of rectocele and pelvic organ prolapse. Patients who are candidates for surgical correction should undergo a careful preoperative assessment that includes treatment of contributing medical problems, identification of all support defects, and evaluation of pelvic floor function. Surgeons who perform reconstructive procedures for rectocele and pelvic organ prolapse should be familiar with multiple surgical procedures because intraoperative modification of the preoperative plan may be required. Thorough knowledge of the anatomy and physiology of these disorders allows selection of a surgical approach that is usually successful in relieving symptoms and restoring and preserving anatomic relationships, visceral function, and coital function long term.

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: I am on the Board for the Society of Gynecologic Surgeons (SGS). SGS is a non-profit organization whose mission is: "is to promote excellence in gynecologic surgery through acquisition of knowledge and improvement of skills...".

Sites of occurrence.

The vagina and supportive structures. Paracolpium extends along the lateral wall of the vagina.

Level I is suspension and level II is attachment. The paracolpium suspends the vagina from the lateral pelvic walls in level I. These fibers extend vertically and posteriorly toward the sacrum. The vagina in level II is attached to the arcus tendineus fascia of the pelvis and superior fascia of the levator ani.

Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.

An Allis clamp tracts upward in the midline of the distal posterior vaginal wall at the site of the bulge. Traction is applied laterally and outward to create a flat triangle. The vaginal wall is then dissected off the anterior wall of the rectum.

In A, penetration with the fifth finger establishes direct access to the levator ani, bilaterally. In B, Allis clamps are placed on both sides. Traction on these clamps elevates the posterior wall of the vagina and places the junction of the rectal and vaginal walls under tension. An incision with a scalpel at this site separates the rectum from the posterior vaginal wall.

In A and B, rectocele is imbricated. Several layers may be required. Dense connective tissue must be identified and plicated. In C, levator ani are brought into the field from their lateral position and sutured in the midline, anterior to the rectum. Some authors omit this step secondary to postoperative pain.

In A, a second suture is placed into the levator ani to reduce the dimension of the genital hiatus. The more anterior these sutures, the smaller the genital hiatus. In B, redundant vaginal wall is trimmed.

In A, the perineal body is repaired. In B, the perineum is rebuilt. In C and D, the posterior vaginal wall is closed.

Sites of occurrence.

The vagina and supportive structures. Paracolpium extends along the lateral wall of the vagina.

Level I is suspension and level II is attachment. The paracolpium suspends the vagina from the lateral pelvic walls in level I. These fibers extend vertically and posteriorly toward the sacrum. The vagina in level II is attached to the arcus tendineus fascia of the pelvis and superior fascia of the levator ani.

Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.

An Allis clamp tracts upward in the midline of the distal posterior vaginal wall at the site of the bulge. Traction is applied laterally and outward to create a flat triangle. The vaginal wall is then dissected off the anterior wall of the rectum.

In A, penetration with the fifth finger establishes direct access to the levator ani, bilaterally. In B, Allis clamps are placed on both sides. Traction on these clamps elevates the posterior wall of the vagina and places the junction of the rectal and vaginal walls under tension. An incision with a scalpel at this site separates the rectum from the posterior vaginal wall.

In A and B, rectocele is imbricated. Several layers may be required. Dense connective tissue must be identified and plicated. In C, levator ani are brought into the field from their lateral position and sutured in the midline, anterior to the rectum. Some authors omit this step secondary to postoperative pain.

In A, a second suture is placed into the levator ani to reduce the dimension of the genital hiatus. The more anterior these sutures, the smaller the genital hiatus. In B, redundant vaginal wall is trimmed.

In A, the perineal body is repaired. In B, the perineum is rebuilt. In C and D, the posterior vaginal wall is closed.